World Mental Health Surveys: A Global Perspective of the Burdens of Mental Disorders

Transcription

1 EUROPEAN COMMISSION. HEALTH AND CONSUMERS DIRECTORATE-GENERAL Governmental Experts on Mental Health and Well-being Luxembourg, 3-4 December 2014 World Mental Health Surveys: A Global Perspective of the Burdens of Mental Disorders Jordi Alonso, MD PhD Director, Program Epidemiology & Public Health, IMIM-Hospital del Mar Medical Research Institute. CIBER in Epidemiology & Public Health, Barcelona, Spain

2 WMH Surveys : A Global Perspective of the Burdens of Mental Disorders Content of the presentation 1. Background 2. Methods of the WMH 3.Frequency and severity of mental disorder 4.Burdens of mental disorders 5.Stigma and Family burden 6.Services use and unmet need for care 7.Discussion 2

3 WMH Surveys : A Global Perspective of the Burdens of Mental Disorders Funding for the European component: European: QLG SANCO EAHC National/Regional ISC III FIS00/0028 ISC III CIBER CB06/02/0046 SAF CE Piedmonte Region 3

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5 Global Burden of Disease: DALYs Disability-Adjusted Life Years, (developed countries) Murray CJL, et al. Lancet 2013; 381:

6 Mental Disorders GBD % DALYs 183,900,000 DALYs 8,600,000 YLL 175,300,000 YDL 5th cause (CV, Infections, Neonatal, Cancer) Increase since 1990: 37,6%, due to population growth & ageing 6

7 Global Burden of Disease: Total Costs of Brain Disorders, Europe 2010 TOTAL COST= 798 billion (461 billion Mental) Gustavsson A, et al. Eur Neuropsychopharmacol 2011; 21:

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9 WMH: the research project 9

10 WHO WMH Survey Initiative Major objectives Prevalence of mental disorders and associated risk factors Prevalence of comorbidity Disability impact Use of services (and unmet need) 10

11 WHO WMH Survey Initiative 11 Blue Finished; Orange Survey work 11

12 WHO WMH Survey Initiative Samples Adult general population (nation/region) About 5,000 per country Cross-sectional surveys Home interviews face to face CAPI or PAPI versions Clinical re-appraisal (SCID) 12

13 WHO WMH Surveys Initiative CIDI 3.0: Content outline Screening and lifetime review Disorders: Mood, Anxiety, Substance, Childhood, Others Functioning and Physical disorders Suicidality, 30-day function, 30-psyhcological distress, physical co-morbidity Treatment Risk factors 13

14 WHO WMH Surveys Initiative Associated factors Family history Traumatic experiences Childhood disorders Personality Spouse information Socio-demographics (Age, Gender, Education, Marriage, Employment...) 14

15 Surveys analyzed WHO WMH Survey Initiative 24 completed countries analysed (2010) RR = 73% (45.9% France, 98.6% India) Questionnaire versions: PAPI (9 countries): Brazil (Sao Paulo Megacity) Bulgaria, China (Beijing/Shanghai; Shenzhen), India (Pondicherry), Iraq, Lebanon, Nigeria, South Africa, Ukraine. CAPI (15 countries): Belgium, Colombia, France, Germany, Israel, Italy, Japan, Mexico, the Netherlands, New Zealand, Northern Ireland, Portugal, Romania, Spain, United States. 15

16 WHO WMH Survey Initiative Mental disorders Mood: MDE Bipolar Dysthymia Anxiety: GAD Panic PTSD Social Phobia Specific Phobias Alcohol, Substance Abuse/Dependence 16

17 WHO WMH Surveys Initiative Chronic Physical Conditions Arthritis Cancer Cardiovascular Heart attack, heart disease, hypertension, stroke Chronic Pain conditions Back, Neck Diabetes Digestive Stomach or intestine ulcer, irritable bowel d. Severe Headaches/Migraine Neurological MS, Parkinson s, Epilepsy, Seizures Respiratory Allergies, Asthma, COPD, Emphysema 17

18 WHO WMH Surveys Initiative 2-phase design Part 1: all Screening section, selected questions on mood and anxiety disorders, detailed questions on services, health status, demographic and others Part 2: 100% of those with specific symptoms or psychological distress 25% random of low impaired 18

19 WMH: Frequency 19

20 WHO WMH Surveys Initiative Total: Age: 121,899 participants 43.3 years Gender: 51.7 % females Previous 12-months Mental disorder: 14.2 % Chronic Physical condition: 57.3 % 20

21 Any mental disorder (12-month) in the WMH surveys US Portugal Ukraine Colombia Lebanon Netherlands Mexico China Bulgaria Israel Romania Nigeria Kessler RC, et al. Chapter 5. In: Patel, Minas, Cohen & Prince, eds. Global Mental Health. Oxford University Press 2014; WHO African Region WHO Region of the Americas WHO South-East Asia Region WHO European Region 21 WHO Eastern Mediterranean Region WHO Western Pacific Region

22 Severity of any mental disorders (12-month) in the WMH surveys United States Ukraine Colombia New Zealand France Lebanon South Africa Netherlands Mexico Belgium Germany Israel Spain Italy Japan PRC Nigeria 6,8 4,9 4,9 5,2 3,5 4 4,3 4,2 3,4 4,2 2,3 3,7 5,3 4,2 4,5 5 4,7 3,5 10,6 9,6 8,4 8,1 8,6 7,5 8,4 7 8,1 7,3 7,6 6,3 7,1 5,2 5, ,8 1,9 4,1 3,7 1,4 4,2 3,2 1 3,4 3,1 1 2,3 3,8 0,8 0,8 4, Severe Moderate Mild 22 Alonso J, et al. Chapter 2. In:Samuel O. Okpaku, ed. Essentials of Global Mental Health. Cambridge University Press 2014;

23 Age of Onset (AOO) of phobias in the WMH surveys Kessler RC, et al. Chapter 5. In: Patel, Minas, Cohen & Prince, eds. Global Mental Health. Oxford University Press 2014;

24 Age of Onset (AOO) of substance disorders in the WMH surveys Kessler RC, et al. Chapter 5. In: Patel, Minas, Cohen & Prince, eds. Global Mental Health. Oxford University Press 2014;

25 Age of Onset (AOO) of mood disorders in the WMH surveys Kessler RC, et al. Chapter 5. In: Patel, Minas, Cohen & Prince, eds. Global Mental Health. Oxford University Press 2014;

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27 WMH Burdens Framework 27 Alonso J, Chatterji S & He Y, eds.the Burdens of Mental Disorders: Global Perspectives from the WHO WMH Surveys. Cambridge University Press 2013: (figure pp. 3)

28 WHO WMH Surveys Initiative Early Termination of Education, by country level 60 % terminating prior to milestone Terminated primary Terminated secondary Did not enter college Terminated college Low/lower-middle Upper-middle High Alonso J, Chatterji S & He Y, eds.the Burdens of Mental Disorders: Global Perspectives from the WHO WMH Surveys. Cambridge University Press 2013: (figure, pp. 58) 28

29 WHO-WMH Surveys Initiative Event Histories Discrete-time survival analysis Each year at risk, a different observation Chronological Age as time scale Database analysed with Logistic Regression Lifetime disorder are time-varying Model examined Interaction: person-years*predictor variables Interaction: predictor variables*country income level 29

30 Early Education Termination & Prior Mental Disorders OR of Not Completing Secondary Education (vs no disorder) Mental disorders Low/Lowermiddle Uppermiddle High Mood * 1.5* Anxiety * Disruptive behavior * 1.8* Substance * Any disorder (1) * Any 2 disorders 1.4* * Any 3 disorders * 2.2* * p< Lee S, et al. Br J Psychiatry 2009; 194:

31 Divorce & Prior Mental Disorders OR of Divorce (vs no disorder) Types of disorders OR Major depressive disorder 1.5* Post-traumatic stress 1.4* Agoraphobia 1.3 * Separation anxiety 1.3* Alcohol abuse 1.4* Specific phobia 1.1* *p< Breslau J, et al. Acta Psychiatr Scand 2011; 124:

32 Divorce & Prior Mental Disorders OR of Divorce (vs no disorder) and Population Attributable Risk Proportion -PARP (% of all divorces) Types of disorders OR PARP (%) Major depressive disorder 1.5* 4.0 Post-traumatic stress 1.4* 1.0 Agoraphobia 1.3 * 0.4 Separation anxiety 1.3* 0.9 Alcohol abuse 1.4* 2.9 Specific phobia 1.1* 1.3 *p<.05 12% 32 Breslau J, et al. Acta Psychiatr Scand 2011; 124:

33 Marital violence & Prior Mental Disorders OR of M. Violence (vs no disorder) and PARP (% of all M. Violence) Disorders OR PARP (%) All disorders All externalizing disorders Husband s externalizing 1.7* 9.5 Wife s externalizing 1.3* 2.0 All internalizing disorders Husband s internalizing Wife s internalizing 1.2* 4.8 *p< Miller E, et al. Br J Psychiatry 2011; 199:

34 Serious Mental Disorders & personal income Estimated effect of SMD and income (overall & components) Overall association Female Male Total Estimate SMI and earnings (total sample) a 0.17* 0.48* 0.29* Component effects SMI & probability of >0 earnings b 0.08* 0.12* 0.10* SMI & earnings, given >0 earnings a 0.15* 0.39* 0.24* *p< Levinson D, et al. Br J Psychiatry 2010; 197:

35 Individual effects: # Days Totally Out of Role/year M= 31.2 P= Alonso J, et al. Mol Psychiatry 2011; 16:

36 Societal effects (PARPs, %): Days Totally Out of Role Alonso J, et al. Mol Psychiatry 2011; 16: % 48%

37 High-income Upper-middle Low/lower-midlle Total Sample 17,289 11,464 14,979 Ill 1st degree relative 41% 31% 19% Any kind of Burden 39% 39% 40% Devoting time 28% 22% 31% Financial burden 11% 13% 19% Psychological distress 23% 27% 27% Embarrassment 6% 17% 9% Viana MC, et al Rev Bras Psiquiatr 2013; 35:

38 I. Time (hours per week) Objective Family Burden Upper- Low/lower- High middle Middle Total Est (se) Est (se) Est (se) Est (se) Individual level (mean) 13.3 (0.7) 16.5 (1.6) 12.9 (0.9) 13.9 (0.6) Per 100 persons (total) (2.2) (1.6) 83.7 (2.8) (1.2) II. Financial (% of median household income) Individual level 15.1 (0.9) 32.2 (2.1) 44.1 (5.3) 24.0 (1.1) Per 100 persons 0.50 (0.02) 1.09 (0.04) 1.81 (0.07) 1.01 (0.03) 38 Viana MC, et al. Rev Bras Psiquiatr 2013; 35:

39 Stigma 39

40 Alonso J, et al. Acta Psychiatr Scand 2008; 118: Embarrassment/Discrimination: Anxiety disorders OR=

41 Alonso J, et al. Acta Psychiatr Scand 2008; 118: Embarrassment/Discrimination: Depressive Disorders OR=

42 Alonso J, et al. Acta Psychiatr Scand 2008; 118: Embarrassment/Discrimination: Co-morbid Anx &Dep OR=

43 43 Alonso J, et al. Acta Psychiatr Scand 2008; 118: Embarrassment/Discrimination: Number of disorders All countries Developed countries Developing countries One physical condition 2+ physical conditions Anxiety disorder Mood disorder Comorbid anxiety and mood 0,1

44 Embarrassment/Discrimination: # of disorders All countries Developed countries Developing countries One physical condition 2+ physical conditions Anxiety disorder Mood disorder Comorbid anxiety and mood 0,1 44 Alonso J, et al. Acta Psychiatr Scand 2008; 118:

45 Family Health Conditions and Family Embarrassment Family Situation OR P value Medical condition only (ref.) -- Mental disorder only 3.7 <0.001 Medical + Mental 2.2 < Ahmedani BK, et al. Psychol Med 2013; 43:

46 Chronic Physical Conditions 46

47 Any early-onset (<21y) Mental Disorders & subsequent Chronic Physical Conditions OR of Physical Condition (vs no early disorder) Chronic Physical Condition OR (95% CI) Arthritis 1.4* ( ) Asthma 1.6* ( ) Back/neck pain 1.6* ( ) Diabetes 1.2 ( ) Severe Headache/Migraine 1.8* ( ) Heart disease 1.6* ( ) *p< McLaughlin KA, et al. Br J Psychiatry 2012; 200:

48 Services 48

49 % Using Services among those with 12-m MDE Spain Portugal New Zealand US Belgium North Ireland Netherlands France Germany Italy Israel Japan Bulgaria Brazil Romania Mexico Colombia Lebanon Nigeria South Africa Ukraine Iraq China India (Pondich) Wang PS, et al. Lancet 2007; 370: WHO African Region WHO South-East Asia Region WHO Eastern Mediterranean Region WHO Region of the Americas WHO European Region WHO Western Pacific Region 49

50 ESEMeD / WMH 12-months unmet need for care 100% 90% 80% 70% 60% 58,5 51,7 50% 96,9 40% 30% 20% 10% 0% 15,6 14 5,5 6,5 Mental morbidity in the general population 48,3 Use of care among those with mental health need 3,1 Unmet need for mental health care (in the general population) No lifetime disorder, no subtreshold No lifetime disorder, any subtreshold Any lifetime mental disorder (no 12m) 12-month disorder no-need 12-month need for health care 50 Alonso J, et al. Br J Psychatr 2007; 190:

51 ESEMeD / WMH 12-months unmet need for care 100% 90% 80% 70% 60% 58,5 51,7 50% 96,9 40% 30% 20% 10% 0% 15,6 14 5,5 6,5 Mental morbidity in the general population 48,3 Use of care among those with mental health need 3,1 Unmet need for mental health care (in the general population) No lifetime disorder, no subtreshold No lifetime disorder, any subtreshold Any lifetime mental disorder (no 12m) 12-month disorder no-need 12-month need for health care Unmet need for care 51 Alonso J, et al. Br J Psychatr 2007; 190:

52 ESEMeD / WMH 3.1% of a population of 213 million adults: ~ 6.6 million with unmet need for mental healthcare 52 Alonso J, et al. Br J Psychatr 2007; 190:

53 Perception of need for care Distribution of perception of need and use of services % No lifetime mental disorder, no subthreshold No lifetime mental disorder, any subthreshold Any lifetime mental disorder no 12m Any 12-month mental disorder Perceived need for mental health care % Use of health services % Any disabling 12- month mental disorder 53 Codony M, et al. Psychiatric Services 2009; 60:

54 54 Codony M, et al. Psychiatric Services 2009; 60: Perceived Need & Use of Care among those feeling need Distribution of perception of need and use of services % No lifetime mental disorder, no subthreshold No lifetime mental disorder, any subthreshold Any lifetime mental disorder no 12m Any 12-month mental disorder Perceived need for mental health care % Use of health services % Any disabling 12- month mental disorder

55 Barriers to mental health treatment % for SEEKING treatment Structural barriers 55 Andrade LH, et al. Psychol Med 2014; 44:

56 56 Andrade LH, et al. Psychol Med 2014; 44: Barriers to mental health treatment % Dropping out of Treatment... Structural barriers Attitudinal barriers

57 Use of Services among the Mentally Ill: Variability across countries, more so than prevalence High levels of unmet need for mental health care Much lower use than for physical conditions Lack of perceived need Both structural and, especially, attitudinal barriers 57

58 Burden of Mental Disorders: GBD vs WMH WMH Surveys GBD Mortality -- Yes! Disability Health Conditions Risk Analysis Frequency Health Losses Welfare Loses Disorders Severity PARP 30-day Comorbidity Prevalence Health Losses -- Disorders Health Sates Sequelae Severity PAF Lifetime Comorbidity Prevalence Incidence Remission & Fatality Whiteford HA, et al. Chapter 17. In: Alonso J, Chatterji S & He Y, eds. The Burdens of Mental Disorders: Global Perspectives from the WHO WMH Surveys. Cambridge University Press 2013;

59 .Thank you for your attention! 59